Impact of adherence to key performance indicators on mortality among patients managed for ischemic stroke
Main Article Content
Keywords
Stroke, Brain Ischemia, Risk Factors, Anticoagulants, Guideline Adherence, Professional Practice, Mortality, Registries, Prospective Studies, Survival Analysis, Malaysia
Abstract
Background: Stroke is a leading cause of death worldwide. The cases of acute ischemic stroke are on the increase in the Asia Pacific, particularly in Malaysia. Various health organizations have recommended guidelines for managing ischemic stroke, but adherence to key performance indicators (KPI) from the guidelines and impact on patient outcomes, particularly mortality, are rarely explored.
Objective: This study aims to evaluate the impact of adherence to key performance indicators on mortality among patients managed for ischemic stroke.
Methods: We included all first-ever ischemic stroke patients enrolled in the multiethnic Malaysian National Neurology Registry (NNeuR) - a prospective cohort study and followed-up for six months. Patients’ baseline clinical characteristics, risk factors, neurological findings, treatments, KPI and mortality outcome were evaluated. The KPI nonadherence (NAR) and relationship with mortality were evaluated. NAR>25% threshold was considered suboptimal.
Results: A total of 579 first-ever ischemic stroke patients were included in the final analysis. The overall mortality was recorded as 23 (4.0%) in six months, with a median (interquartile) age of 65 (20) years. Majority of the patients (dead or alive) had partial anterior circulation infarct, PACI (43.5%; 34.0%) and total anterior circulation infarct, TACI (26.1%; 8.8%). In addition, DVT prophylaxis (82.8%), anticoagulant for atrial fibrillation (AF) patients (48.8%) and rehabilitation (26.2%) were considered suboptimal. NAR < 2 was significantly associated with a decrease in mortality (odds ratio 0.16; 0.02-0.12) compared to NAR>2. Survival analysis showed that death is more likely in patients with NAR>2 (p=0.05).
Conclusions: KPI nonadherence was associated with mortality among ischemic stroke patients. The adherence to the KPI was sub-optimal, particularly in DVT prophylaxis, anticoagulant for AF patients and rehabilitation. These findings reflect the importance of continuous quality measurement and implementation of evidence recommendations in healthcare delivery to achieve optimal outcome among stroke patients.
References
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5. Benjamin EJ, et al. Heart Disease and Stroke Statistics—2019 Update: A Report From the American Heart Association. Circulation. 2019 Mar 5;139(10):e56-e528. https://doi.org/10.1161/CIR.0000000000000659
6. Katan M, Luft A. Global Burden of Stroke. Semin Neurol. 2018;38(2):208-211. https://doi.org/10.1055/s-0038-1649503
7. Mehndiratta MM, Khan M, Mehndiratta P, Wasay M. Stroke in Asia: Geographical variations and temporal trends. J Neurol Neurosurg Psychiatry. 2014 Dec;85(12):1308-1312. https://doi.org/10.1136/jnnp-2013-306992
8. Aziz ZA, Lee YY, Ngah BA, Sidek NN, Looi I, Hanip MR, Basri HB. Acute stroke registry Malaysia, 2010-2014: Results from the National Neurology Registry. J Stroke Cerebrovasc Dis. 2015;24(12):2701-2709. https://doi.org/10.1016/j.jstrokecerebrovasdis.2015.07.025
9. Loo KW, Gan SH. Burden of stroke in Malaysia. Int J Stroke. 2012;7(2):165-167. https://doi.org/10.1111/j.1747-4949.2011.00767.x
10. Tharakan J. Stroke registry-relevance and contributions. Med J Malaysia. 2012;67(3):251-252.
11. Hwong WY, Aziz ZA, Sidek NN, Bots ML, Selvarajah S, Kappelle LJ, Sivasampu S, Vaartjes I. Prescription of secondary preventive drugs after ischemic stroke: Results from the Malaysian National Stroke Registry. BMC Neurol. 2017;17(1):203. https://doi.org/10.1186/s12883-017-0984-1
12. Hasan TF, Rabinstein AA, Middlebrooks EH, Haranhalli N, Silliman SL, Meschia JF, Tawk RG. Diagnosis and management of acute ischemic stroke. Mayo Clin Proc. 2018;93(4):523-538. https://doi.org/10.1016/j.mayocp.2018.02.013
13. Goyal M, Fargen KM, Menon BK. Acute stroke, Bayes’ theorem and the art and science of emergency decision-making. J Neurointerv Surg. 2014;6(4):256-259. https://doi.org/10.1136/neurintsurg-2013-011056
14. Romano JG, Smith EE, Liang L, Gardener H, Camp S, Shuey L, Cook A4, Campo-Bustillo I, Khatri P, Bhatt DL, Fonarow GC, Sacco RL, Schwamm LH. Outcomes in mild acute ischemic stroke treated with intravenous thrombolysis: a retrospective analysis of the Get With the Guidelines–Stroke registry. JAMA Neurol. 2015;72(4):423-431. https://doi.org/10.1001/jamaneurol.2014.4354
15. Fonarow GC, Smith EE, Saver JL, Reeves MJ, Bhatt DL, Grau-Sepulveda MV, Olson DM, Hernandez AF, Peterson ED, Schwamm LH. Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes. Circulation. 2011;123(7):750-758. https://doi.org/10.1161/CIRCULATIONAHA.110.974675
16. Fonarow GC, Zhao X, Smith EE, Saver JL, Reeves MJ, Bhatt DL, Xian Y, Hernandez AF, Peterson ED, Schwamm LH. Door-to-needle times for tissue plasminogen activator administration and clinical outcomes in acute ischemic stroke before and after a quality improvement initiative. JAMA. 2014;311(16):1632-1640. https://doi.org/10.1001/jama.2014.3203
17. Fonarow GC, Reeves MJ, Smith EE, Saver JL, Zhao X, Olson DW, Hernandez AF, Peterson ED, Schwamm LH; GWTG-Stroke Steering Committee and Investigators. Characteristics, performance measures, and in-hospital outcomes of the first one million stroke and transient ischemic attack admissions in get with the guidelines-stroke. Circ Cardiovasc Qual Outcomes. 2010;3(3):291-302. https://doi.org/10.1161/CIRCOUTCOMES.109.921858
18. Heuschmann PU, Berger K. International experience in stroke registries: German Stroke Registers study group. Am J Prev Med. 2006;31(6 Suppl 2):S238-S239. https://doi.org/10.1016/j.amepre.2006.08.005
19. Wang Y, Li Z, Zhao X, Liu L, Wang C, Wang C, Peterson ED, Schwamm LH, Fonarow GC, Smith SC Jr, Bettger J, Wang D, Li H, Xian Y, Wang Y. Evidence-Based Performance Measures and Outcomes in Patients With Acute Ischemic Stroke: Findings From the China National Stroke Registry. Circ Cardiovasc Qual Outcomes. 2018;11(12):e001968. https://doi.org/10.1161/CIRCOUTCOMES.115.001968
20. Hsieh F, et al. Taiwan stroke registry investigators. Get with the guidelines-stroke performance indicators: surveillance of stroke care in the Taiwan stroke registry: get with the guidelines-stroke in Taiwan. Circulation. 2010;122(11):1116-1123. https://doi.org/10.1161/CIRCULATIONAHA.110.936526
21. LaBresh KA, Reeves MJ, Frankel MR, Albright D, Schwamm LH. Hospital treatment of patients with ischemic stroke or transient ischemic attack using the “Get With The Guidelines” program. Arch Intern Med. 2008;168(4):411-417. https://doi.org/10.1001/archinternmed.2007.101
22. Schwamm LH, Fonarow GC, Reeves MJ, Pan W, Frankel MR, Smith EE, Ellrodt G, Cannon CP, Liang L, Peterson E, Labresh KA. Get With the Guidelines-Stroke is associated with sustained improvement in care for patients hospitalized with acute stroke or transient ischemic attack. Circulation. 2009;119(1):107-115. https://doi.org/10.1161/CIRCULATIONAHA.108.783688
23. Ellrodt AG, Fonarow GC, Schwamm LH, Albert N, Bhatt DL, Cannon CP, Hernandez AF, Hlatky MA, Luepker RV, Peterson PN, Reeves M, Smith EE. Synthesizing lessons learned from get with the guidelines: the value of disease-based registries in improving quality and outcomes. Circulation. 2013;128(22):2447-2460. https://doi.org/10.1161/01.cir.0000435779.48007.5c
24. Kalkonde YV, Alladi S, Kaul S, Hachinski V. Stroke Prevention Strategies in the Developing World. Stroke. 2018;49(12):3092-3097. https://doi.org/10.1161/STROKEAHA.118.017384
25. Centers for Disease Control and Prevention (CDC). Prevention. Use of a registry to improve acute stroke care--seven states, 2005-2009. MMWR Morb Mortal Wkly Rep. 2011;60(7):206-210.
26. Grube MM, Dohle C, Djouchadar D, Rech P, Bienek K, Dietz-Fricke U, Jöbges M, Kohler M, Missala I, Schönherr B, Werner C, Zeytountchian H, Wissel J, Heuschmann PU. Evidence-based quality indicators for stroke rehabilitation. Stroke. 2012;43(1):142-146. https://doi.org/10.1161/STROKEAHA.111.627679
27. Rohde A, Worrall L, Le Dorze G. Systematic review of the quality of clinical guidelines for aphasia in stroke management. J Eval Clin Pract. 2013;19(6):994-1003. https://doi.org/10.1111/jep.12023
28. Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, Fang MC, Fisher M, Furie KL, Heck DV, Johnston SC, Kasner SE, Kittner SJ, Mitchell PH, Rich MW, Richardson D, Schwamm LH, Wilson JA; American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Peripheral Vascular Disease. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(7):2160-2236. https://doi.org/10.1161/STR.0000000000000024
29. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW Jr, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870-947. https://doi.org/10.1161/STR.0b013e318284056a
30. Nazifah SN, Azmi IK, Hamidon B, Looi I, Zariah A, Hanip M. National Stroke Registry (NSR): Terengganu and Seberang Jaya experience. Med J Malaysia. 2012;67(3):302-304.
31. Amarenco P, Bogousslavsky J, Caplan L, Donnan G, Hennerici M. Classification of stroke subtypes. Cerebrovasc Dis. 2009;27(5):493-501. https://doi.org/10.1159/000210432
32. Appleton JP, Woodhouse LJ, Adami A, Becker JL, Berge E, Cala LA, Casado AM, Caso V, Christensen HK, Dineen RA, Gommans J, Koumellis P, Szatmari S, Sprigg N, Bath PM, Wardlaw JM; ENOS Investigators. Imaging markers of small vessel disease and brain frailty, and outcomes in acute stroke. Neurology. 2020;94(5):e439-e452. https://doi.org/10.1212/WNL.0000000000008881
33. Micieli G, Cavallini A, Quaglini S; Guideline Application for Decision Making in Ischemic Stroke (GLADIS) Study Group. Guideline compliance improves stroke outcome: a preliminary study in 4 districts in the Italian region of Lombardia. Stroke. 2002;33(5):1341-1347. https://doi.org/10.1161/01.str.0000013663.27776.db
34. Rudd AG, Williams LS. Advances in health policy and outcomes. Stroke. 2009 May;40(5):e301-e304. https://doi.org/10.1161/STROKEAHA.108.544551
35. Bravata DM, Wells CK, Lo AC, Nadeau SE, Melillo J, Chodkowski D, Struve F, Williams LS, Peixoto AJ, Gorman M, Goel P, Acompora G, McClain V, Ranjbar N, Tabereaux PB, Boice JL, Jacewicz M, Concato J. Processes of Care Associated With Acute Stroke OutcomesStroke Outcomes and Processes of Care. Arch Intern Med. 2010;170(9):804-810. https://doi.org/10.1001/archinternmed.2010.92
36. Sargin M, Tasdemir MM, Kuplay H, Erdogan SB, Tandogar N, Akansel S, Kurc E, Orhan G, Aka SA.Retrospective cohort study for evaluating the INR monitoring patterns in patients with deep vein thrombosis in daily practice: Analysis of 2010–2013 database of a tertiary care center. Phlebology. 2019;34(5):317-323. https://doi.org/10.1177/0268355518806117
37. Wei JW, Wang J-G, Huang Y, Liu M, Wu Y, Wong LK, Cheng Y, Xu E, Yang Q, Arima H, Heeley EL, Anderson CS; ChinaQUEST Investigators. Secondary prevention of ischemic stroke in urban China. Stroke. 2010;41(5):967-974. https://doi.org/10.1161/STROKEAHA.109.571463
38. Gallacher KI, McQueenie R, Nicholl B, Jani BD, Lee D, Mair FS. Risk factors and mortality associated with multimorbidity in people with stroke or transient ischaemic attack: a study of 8,751 UK Biobank participants. J Comorb. 2018;8(1):1-8. https://doi.org/10.15256/joc.2018.8.129
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Impact of adherence to key performance indicators on mortality among patients managed for ischemic stroke. Pharm Pract (Granada) [Internet]. 2020 Mar. 9 [cited 2025 Mar. 27];18(1):1760. Available from: https://pharmacypractice.org/index.php/pp/article/view/1760
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How to Cite
1.
Impact of adherence to key performance indicators on mortality among patients managed for ischemic stroke. Pharm Pract (Granada) [Internet]. 2020 Mar. 9 [cited 2025 Mar. 27];18(1):1760. Available from: https://pharmacypractice.org/index.php/pp/article/view/1760